CARPAL TUNNEL

SYNDROME

Dr. Angelo Smith

M.D
DEFINITI
ON
• Carpal tunnel syndrome, the
most common focal
peripheral neuropathy,
results from compression of
the median nerve at the
wrist
.
FEATURE • Nerve Entrapment
S • Middle or Advanced
age
• > 40 yrs (>80%)
• 2x in women
• ? Occupational
Disease
MEDIAN NERVE – MOTOR INNERVATION:

1stand the 2ndlumbricals

Muscles of thenar eminence:

1. Opponens pollicis brevis
2. Flexor pollicis brevis

SENSORY INNERVATION:

Skin of the palmar side of the thumb, index

and middle finger.
Half the ring finger and nail bed of these
fingers.
 SIGNS AND
• Tingling SYMPTOMS
• Numbness or discomfort
in the lateral 31/2 fingers
• Intermittent pain in the
distribution of the
median nerve
• Symptoms gets
aggravated at night.
• To relieve the symptoms,
patients often “flick” their
wrist as if shaking down
a thermometer (flick
sign).
MOTOR
CHANGES:
Apelike thumb deformity

Loss of opposition of thumb

Index and middle finger lag behind when making the fist.

SENSORY CHANGES:

Loss of sensation of lateral 3 1/2 digits including the nail bed and distal
phalanges on dorsum of hand
(An important point to remember for Carpal tunnel syndrome is that there is no
sensory loss over the thenar eminence in Carpal tunnel syndrome because the
branch of median nerve that innervates it (palmar cutaneous branch) passes
superficial to Carpal tunnel and not through it).
Finger lag when making a fist

Ape thumb
VASOMOTOR
CHANGES:
• Skin area with sensory loss is warmer
• Dry skin

TROPHIC CHANGES:

• Long standing cases leads to dry and scaly

skin
• Nail crack easily
• Atrophy of the pulp of the fingers.
 DIAGNOSI
Physical Assessment
S
Tests:
• Less sensitivity to pain where the median nerve runs to the
• fingers Thumb weakness
• Inability to tell the difference between one and two sharp points
on the fingertips
• Flick Signal. The patient is asked, "What do you do when
your symptoms are worse?"
If the patient responds with a motion that resembles shaking
a thermometer, the doctor can strongly suspect carpal
tunnel.
PHALEN’S
TEST
 The :patient rests the elbows on a
table
 The wrists dangle( flexion) with fingers pointing down and the backs of the hands pressed
together.

POSITIVE: If symptoms develop within a minute, CTS is indicated.

• TINEL’S SIGN TEST:
In the Tinel's sign test, the doctor taps over the median nerve
to produce a tingling or mild shock sensation.
o DURKAN
TEST:
The doctor presses over the carpal tunnel for 30
seconds to produce tingling or shock in the
median nerve.

o HAND ELEVATION
TEST:
The patient raises his or her hand overhead for
2 minutes to produce symptoms of CTS.
ELECTRODIAGNOSTIC
TEST:
Help detect median nerve compression in the
carpal tunnel.

Nerve Conduction Studies:

To perform nerve conduction studies, surface electrodes

are first fastened to the hand and wrist. Small electric
shocks are then applied to the nerves in the fingers, wrist,
and forearm to measure how fast a signal travels through
the nerves that control movement and sensation.

Electromyography:
To perform electromyography, a thin, sterile wire electrode is
inserted briefly into a muscle, and the electrical activity is
displayed on a viewing screen. Electromyography can be
painful and is less accurate than nerve conduction.
 DIFFERENTIAL
• DIAGNOSIS
Cervical Spondylosis
• Compartment
• Syndrome
Diabetic
• Neuropathy
Ischemic Monomelic
• Neuropathy Lateral
• Epicondylitis
Lyme Disease
• Multiple
• SclerosisInjury
Overuse
• Tumatic Brachial
• Plexopathy
Tendonit
is
 MANAGEME
NT
IMMOBILISING BRACES / SPLINT

Stretching and strengthening exercises can be helpful in

people whose symptoms have abated

Non surgical:
ANALGESICS LIKE NSAID(like aspirin, ibuprofen,and other
pain killers)
Corticosteroids (such as prednisone) or the drug
lidocaine injected directly to the wrist to relieve the pressure
Orally administered diuretics ("water pills") can decrease swelling.
LOCAL
INJECTION
• A mixture of 10 to 20 mg of lidocaine (Xylocaine) without epinephrine and 20 to
40 mg of methylprednisolone acetate (Depo-Medrol) or similar corticosteroid
preparation is injected with a 25-gauge needle at the distal wrist crease (or 1 cm
proximal to it).
 LOCAL
•INJECTION
Splinting is generally recommended after
local
corticosteroid injection.
• If the first injection is successful, a repeat injection can be
considered after a few months
• Surgery should be considered if a patient needs more than
two injections
Surgical
:• Generallyrecommended if symptoms last for 6
months, surgery involves severing the band of tissue
around the wrist to reduce pressure on the median
nerve.
TWO TYPES OF CTS RELEASE SURGERY:

Open release surgery

Endoscopic surgery
Open Endoscopic
Release Release
OPEN
SURGERY
OPEN
SURGERY
 Complications of
• surgery
Injury to the palmar cutaneous or recurrent
motor branch of the median nerve
• Hypertrophic scarring
• laceration of the superficial palmar arch
• tendon adhesion
• Postoperative infection
• Hematoma
• arterial injury
• stiffness
 PREGNANC
• Y
Alterations in fluid balance may predispose some
pregnant women to develop carpal tunnel
syndrome.
• Symptoms are typically bilateral and first noted
during the third trimester.
• Conservative measures are appropriate, because
symptoms resolve after delivery in most women
with pregnancy-related carpal tunnel syndrome.